COVID Antigen Test - Patient Registration Form

First Name

Last Name

MI

Email Address

Sex

Date of Birth

Race

Ethnicity

Patient Address

City

State

Zipcode

Patient County of Residence

Patient Phone Number

Vehicle Description

History of Present Illness

Do you have any symptoms of COVID-19?

Yes

No

If yes, when did the symptoms start?

Have you had a known exposure to COVID-19?

Yes

No

If so, when?

By signing below, I consent to receive the CareStart COVID-19 Antigen Rapid POC Test. I also recognize that, pursuant to South Carolina Law §44-29-10 and Regulation §61-20, my results will be reported to the SC Department of Health and Environmental Services, whether positive or negative.

Patient/Representative Signature

Date

For Pharmacy Use Only

Specimen ID

Test Collected

Results Read

Signature of Administering Pharmacist

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